Shaken Baby Syndrome and Implications for School Psychology
Tiffany S. Folmer and Paul C. McCabe

The role of the school psychologist is expanding beyond secondary and tertiary intervention to include primary prevention efforts aimed at thwarting trauma and abuse to children. School psychologists, among a number of medical health and mental health professionals, are required by legal and ethical mandates to report suspected cases of maltreatment. To do so, the school psychologist needs to be knowledgeable of the signs and symptoms of possible abuse, as well as associated risk factors. One form of child abuse, Shaken Baby Syndrome (SBS), has been receiving an increasing amount of attention, both in terms of research focus and media awareness. Although most school psychologists work outside the purview of direct infant care, there is compelling evidence suggesting that primary prevention efforts enacted by school professionals with at-risk populations can successfully prevent SBS, thus saving lives and precluding untoward physiological and psychopathological sequelae. In addition to primary prevention, school psychologists can also play a role in identifying ongoing occurrences of SBS to prevent future incidents. Accordingly, it is important for school psychologists to be aware of the physical symptoms of SBS, including retinal hemorrhaging, as well as related at-risk factors, to be able to make informed decisions regarding child abuse reporting and intervention strategies.

SBS occurs when someone shakes a baby or infant either gently or violently. SBS has been associated with infantile death and numerous forms of developmental delays in those who survive. The most common event leading up to the incident of shaking is extreme crying during which the baby cannot be comforted (Lancon, Haines & Parent, 1998). Babies' heads make up about 10% of their total volume and weight, and the muscles that hold the head are extremely weak. Therefore, even a short or relatively gentle episode of shaking can cause trauma in the brain. However, there are not clear ways to diagnose this form of abuse, and there is debate over the presenting symptoms of SBS.

Prevalence and Risk Factors for SBS

Typically, victims of shaken baby syndrome are children under one year of age (Lancon et al., 1998). Riffenburgh and Sathyavagiswaran (1991b) indicated that as a child's age increases, the occurrence of shaking decreases as increasing strength and weight makes older children more difficult to shake. Lancon et al. (1998) also reported that males are more likely to be victims of SBS than are females, and 90% of the perpetrators of this form of abuse are male. However, when the perpetrator is a female, it is often a babysitter. Kivlin (2001) reported that 1800 children suffer from SBS annually in the United States, and that of these, one-third sustain fatal injuries. She also asserted that several episodes of shaking often occur before the infant passes away, and therefore early detection of the subtle signs of shaking is vital in saving the child's life.

Kapoor et al. (1997) indicated that some risk factors for SBS include "previous involvement with Child Protective Services, a history of spousal abuse, single parent families, parents who are younger than 18, parental drug and alcohol use, low socioeconomic status, or parental history of child abuse or neglect" (p. 184). However, others have not supported this assertion. At a conference on Shaken Baby Syndrome in 1996, researchers reported that SBS is not highly correlated to socioeconomic status, ethnicity, parental age or level of education (Lancon et al., 1998).

 

Presentation of SBS

Many authors state that shaken babies often do not show the typical signs of abuse, which causes difficulty in detection (Kivlin, 2001; McCabe & Donahue, 2000; Riffenburgh & Sathyavagiswaran, 1991a). Symptoms of SBS may be internal, including subdural hemorrhages and retinal hemorrhages (Lancon et al., 1998). Spaide (1997) listed many possible presenting signs of a baby who has suffered from SBS, including failure to thrive, hypothermia, lethargy, listlessness, vomiting, seizures, hemiplegia, coma and bulging anterior fontanels (p. 109). Lambert et al. (1986) suggested that when a child exhibits external signs of shaking, the classic sign is thumbprints on the chest. In those children who survive SBS, epilepsy, vision loss and mental retardation are common (Riffenburgh & Sathyavagiswaran, 1991b).

 

Retinal Hemorrhages as Diagnostic Criteria for SBS

John Caffey was the first to point out that shaking a young child could cause retinal hemorrhages (Kapoor et al., 1997). McCabe and Donahue (2000) asserted that unexplained and extensive retinal hemorrhages in infants are almost diagnostic of SBS. Riffenburgh and Sathyavagiswaran (1991a) also pointed out that retinal hemorrhage is one of the most common findings in children who suffer from SBS. Kivlin (2001) reported that 50-100% of SBS victims experience retinal hemorrhages. However, Munger, Peiffer, Bouldin, Kylstra, and Thompson (1993) previously argued that that while retinal hemorrhages occur frequently in SBS, they are neither necessary for diagnosis nor a symptom exclusively of SBS.

To determine a link between SBS and retinal hemorrhages, and to address the question of whether or not retinal hemorrhages could be considered a diagnostic criterion of SBS, Riffenburgh and Sathyavagiswaran (1991b) examined 77 pairs of eyes attained from autopsies. Forty-seven pairs of eyes (61%) had retinal hemorrhages and 30 pairs of eyes showed no hemorrhages. Those with hemorrhages varied from massive bleeding involving the whole retina to those with only a few blood cells in the retina. Of these 47 cases, only 23 (49%) of the babies showed external indicators of abuse. However, of the 30 nonhemorrhagic cases, 25 showed evidence of external trauma. Forty of the cases examined died as a result of Sudden Infant Death Syndrome (SIDS), and of these, none showed retinal hemorrhages. These authors concluded that retinal hemorrhage is a very strong indication of shaking or head injury or both, and can help to rule out a diagnosis of SIDS.

Wilkinson, Han, Rappley, and Owings (1989) conducted a study with 14 cases of child survivors of SBS. SBS was diagnosed based on the presence of intraocular hemorrhage and intracranial injury without external signs of head trauma. They found that the children with more severe hemorrhages were positively correlated with greater neurological difficulties. Several researchers suggest using computed tomographic scans and dilated retinal examination performed by an ophthalmologist to rule out or diagnose SBS (Dorfman & Paradise, 1995; McCabe & Donahue, 2000). Other researchers strongly suggest that any child who dies without obvious causes should have autopsies including an eye exam (Riffenburgh & Sathyavagiswaran, 1991b).

Differential Diagnosis

Difficulties other than abuse that can cause ocular trauma need to be ruled out in the case where SBS is indicated. For instance, McCabe and Donahue (2000) indicated that retinal hemorrhages could result from accidental head trauma, seizures, and cardiopulmonary resuscitation. It is important to complete a careful history and physical examination to determine the reason for the hemorrhages. Retinal hemorrhages often occur during the birth process, but after the neonatal period these hemorrhages are rare. Therefore, some researchers believe retinal hemorrhages should be considered a sign of child abuse (Lambert, Johnson & Hoyt, 1986; Spaide, 1987).

Additionally, neurologists are often consulted to assess whether or not the child's injuries are consistent with accidental trauma or shaking (Duhaime et al., 1987). Those who shake a baby often deny their involvement in the child's injury, and often report that accidental falls are to blame for the child's injuries. Many studies have shown that the type of brain injury that occurs would require a fall of at least four to five feet onto a hard surface (Lancon et al., 1998). However, the most common explanation is that the child fell out of a bed (2-3 feet).

 

Critique of Available Literature

An obvious difficulty with this research is that hemorrhages can only be studied in retrospect, and thus identifying exactly why shaking causes these hemorrhages is difficult. Although attempts at simulating shaking have allowed researchers to make some interesting conclusions, these types of investigations are few and far between.

Another limitation of the extant literature is that accurate histories and information regarding the cases are difficult to attain, as people are frequently dishonest about their involvement with the child's injuries. This brings into question the integrity of the samples, as some children may have been a victim of SBS but not included in a study, or included as a control participant rather than as part of the experimental group based on the inaccurate reports of the caretakers. In addition, the lack of specific diagnostic criteria for SBS make it difficult for researchers to definitively identify SBS cases.

Implications for School Psychologists

As many cases result in death, SBS may not seem like an issue that is directly related to the work of school psychologists. However, Chiocca (1995) stated that victims of abuse might recover physically but still experience a variety of psychological difficulties including low levels of achievement, shyness, low self-esteem and higher levels of acting out behavior. Chiocca stated that SBS causes serious intellectual impairments and brain damage. Ludwig and Warman (1984) studied 20 cases of SBS, and found that 15% died, while 50% of the survivors experienced common effects of SBS such as visual impairments, motor impairments, seizures, and developmental delays. Only 35% survived without experiencing any difficulty following an incident of shaking. Many cases of SBS go unnoticed, and special educators may encounter students with these problems who may have been a victim of SBS.

A major risk factor for SBS is parents having developmentally inappropriate expectations of a child (Butler, 1995). Chiocca (1995) stated that the primary reason parents have unrealistic expectations is a lack of knowledge about developmentally appropriate behaviors. School psychologists and other educators are instrumental in providing community education programs that outline development milestones, methods to nurture children, dealing with stress and frustration, and ways to prevent SBS. This is particularly important for parents still in high school, as becoming a parent at a young age is a significant risk factor for perpetrating child abuse (Kruger, 1997; Swenson & Levitt, 1997). Additionally, since babysitters sometimes perpetrate SBS, they should be trained in ways to deal with a crying or colicky baby.

Swenson and Levitt (1997) provided several suggestions for physicians to be more involved with the prevention of SBS. Many of these suggestions can be extended to the school psychologist's role as well. For instance, they recommended that professionals become aware of community resources such as parent support groups and parenting classes. School psychologists can refer families to agencies that can help them deal with the stressors of having a newborn and provide them with developmental information about their babies. Additionally, the authors recommended providing information about SBS for parents to take home. While the psychologist's focus is typically on school aged children, parents often have other children at home, and providing this information can be helpful in preventing SBS and ensuring the safety of all children. The authors also noted that it is important to validate parents' concerns and frustrations about having a baby in the home. School psychologists can help provide empathetic support and suggestions for parents who report they are experiencing high levels of stress in the home.

Showers (2001) argued that the responsibility of educating people about SBS falls on all professionals who work with parents or children. She stated that school professionals are in a position where they can provide education in a brief session to parents as well as students who might become babysitters or parents. In addition, Kruger (1997) indicated that research on the effects of SBS from a psychoeducational perspective is lacking. School psychologists could join other educators and professionals in adding to the research base and helping to elucidate the physical, psychological, and educational ramifications of SBS.

Lastly, it is important that psychologists consider their ethical and legal requirements to report suspected cases of abuse. When children present with unexplained symptoms associated with SBS, it is important to gather all supporting information, and if indicated, make referrals for CT scans or eye examinations to rule out SBS. This action is not only prudent and lawful, but could ultimately save a child's life.

References

Chiocca, E.M. (1995). Shaken baby syndrome: A nursing perspective. Pediatric Nursing, 21(1), 33-38.

Butler, G.L. (1995). Shaken baby syndrome. Journal of Psychosocial Nursing, 33(9), 47-50.

Dorfman, D., Paradise, J. (1995). Emergency diagnosis and management of physical abuse and neglect of children. Current Opinion in Pediatric Ophthalmology, 7, 297-301.

Duhaime, A., Gennarelli, T., Thibault, L., Bruce, D., Margulies, S., & Wiser, R. (1987). The shaken baby syndrome. Journal of Neurosurgery, 66, 409-415.

Kapoor, S., Schiffman, J., Tang, R., Kiang, E., Li, H., & Woodward, J. (1997). The significance of white-centered retinal hemorrhages in the shaken baby syndrome. Pediatric Emergency Care, 13(3), 183-185.

Kivlin, J. (2001). Manifestations of the shaken baby syndrome. Current Opinion in Ophthalmology, 12, 158-163.

Kruger, N. (1997). Shaken baby syndrome: Identification and prevention by early childhood educators. South African Journal of Education, 17(3), 107-115.

Lambert, S., Johnson, T., & Hoyt, C. (1986). Optic nerve sheath and retinal hemorrhages associated with the shaken baby syndrome. Archives of Ophthalmology, 104, 1509-1512.

Lancon, J., Haines, D., & Parent, A. (1998). Anatomy of the shaken baby syndrome. The Anatomical Record, 253(1), 13-18.

Ludwig, S., & Warman, M. (1984). Shaken baby syndrome: A review of 20 cases. Annals of Emergency Medicine, 13(2), 104-107.

McCabe, C., & Donahue, S. (2000). Prognostic indicators for vision and mortality in Shaken Baby Syndrome. Archives of Ophthalmology, 118, 373-376.

Munger, C., Peiffer, R., Bouldin, T., Kylstra, J.& Thompson, R. (1993). Ocular and associated neuropathic observations in suspected whiplash shaken infant syndrome. The American Journal of Forensic Medicine and Pathology, 14(3), 193-200.

Riffenburgh, R., & Sathyavagiswaran, L. (1991a). Ocular findings at autopsy of child abuse victims. Ophthalmology, 98(10), 1519-1524.

Riffenburgh, R., & Sathyavagiswaran, L. (1991b). The eyes of child abuse victims: Autopsy findings. Journal of Forensic Science, 36(3), 741-747.

Showers, J. (2001). Preventing Shaken baby syndrome. Journal of Aggression, Maltreatment and Trauma, 5(1), 349-365.

Spaide, R. (1987). Shaken baby syndrome: Ocular and computed tomographic findings. Journal of Clinical Neuro-Ophthalmology, 7(2), 108-111.

Swenson, J. & Levitt, C. (1997). Shaken baby syndrome: Diagnosis and Prevention. Minnesota Medicine, 80 (6), 41-44.

Wilkinson, W.S., Han, D.P., Rappley, M.D., & Owings, C.L. (1989). Retinal hemorrhage predicts neurologic injury in the Shaken Baby Syndrome. Archives of Ophthalmology, 107, 1472-1474.